Fillable Application - Youth Organizations36-9283

Fill Online, Printable, Fillable, Blank Application - Youth Organizations36-9283 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Youth Organizations36-9283

On average this form takes 248 minutes to complete

The Application - Youth Organizations36-9283 form is 23 pages long and contains:

  • 0 signatures
  • 139 check-boxes
  • 928 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
YOUTH GROUP ORGANIZATION SUPPLEMENTAL
Named Insured:
Location Address:
E-mail:
FEIN Number:
Person to contact for safety questions/mailings/info:
Web Address:
Risk Management Contact:
Cell Phone:
Email:
REQUIREMENTS FOR SUBMISSION
• Completed and signed/dated PHLY Youth Group Organization Supplemental Application
• Completed ACORD Applications
• Currently valued insurance company loss runs for current policy period plus three (3) prior years
•
Statement of Values (for blanket and agreed amount property coverage)
•
Athletic Participants sample Waiver Forms
•
Brochures / Promotional Materials
This application consists of the following sections. Complete all sections that apply. Some questions may not apply to
Applicant’s operations. In that case, please put an N/A in the space for the answer.
SECTION I – GENERAL APPLICATION INFORMATION
Type of program:
Boys’ / Girls” Club
Camp Fire Councils
Indian Guides
Other:
Boy Scouts
Girl Scouts
JCC
What are the Applicant’s hours of operation? From: To:
Number of members: Number of active members: Staff to child ratio:
How long has the Applicant’s director been in his or her position with their facility?
How many total years experience does the director have as a facility director?
Does the director or any other employee train outside groups in anything, such as CPR or
lifesaving?
Yes
No
If yes, describe:
4. Does the Applicant loan or lease their director or employees to any other operations either owned or
not owned?
Yes
No
If yes, explain who, how often, and for what purpose:
Section I - General Application Information
Section XII - Hired and Non
-Owned
Section II - Management Practices
Section XIII - Day Care
Section III - Professional Liability
Section XIV - Camps
Section IV - Hiring / Screening
Section XV - Activities
Section V - Sexual Abuse
Section XVI - Trips / Field Trips / Travel
Section VI - Swimming Pools
Section XVII – Special Needs Participants
Section VII - Premises / Life Safety
Section XVIII – Facility Rental
Section VIII – Kitchen Exposure
Section XIX – Claims Made
Section IX - Security
Section XX – D & O / Employment Practice Liability
Section X - Automobile
Section XXI – Winter Weather Freeze
-Up Protection
Section XI - Drivers
Youth Group Organization Supplemental
Page 1 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Print Application
Clear Application
Does the Applicant dispense medication?
Yes
No
If yes, are written instructions from parents required prior to administering medications to minors?
Yes
No
a.
Is all medication stored in its original containers?
Yes
No
b.
Is all medication inaccessible to children?
Yes
No
c.
How many of the following medical professionals are on staff?
RN:
LPN:
EMT:
MD:
PA:
Other:(describe):
d.
Do the professionals carry their own malpractice insurance?
Yes
No
If yes, does Applicant request a certificate of insurance as proof?
Yes
No
e.
Are any of the medical professionals volunteers?
Yes
No
f.
Is a log kept to record each time a medication is administered?
Yes
No
Does the Applicant accept special needs participants?
Yes
No
If yes, please complete Section XVII
Does the Applicant take participants on field trips or travel?
Yes
No
If yes, please complete section XVI
Does the Applicant rent or lease their facility to outside entities?
Yes
No
If yes, complete Section XVIII
Does the Applicant sponsor or participate in special events or fundraisers?
Yes
No
If yes, please list all types of events. Use additional paper if needed.
What is the Applicant’s income from all sources (last 12 months)?
Membership Fees:
$
Snack Bar:
$
Fund Raisers:
$
User Fees:
$
Donations:
$
Child Care:
$
Other:
$
Other:
$
Bingo (indicate # of admissions annually)
TOTAL ALL RECEIPTS:
$
JCC’s only: Does the Applicant sponsor or participate in the Maccabi Games?
Yes
No
Girl Scouts only: Does the Applicant allow scouts to go unaccompanied door-to-door selling?
Yes
No
Does the Applicant accept adjudicated youth or adults as volunteers?
Yes
No
SECTION II – MANAGEMENT PRACTICES
Does the Applicant have sign in / out procedures for:
Staff?
Yes
No
Clients / Residents?
Yes
No
Visitors / Public?
Yes
No
Are all minors required to sign in?
Yes
No
Are all entrances attended?
Yes
No
Type of security provided for the protection of the Applicant’s clients / residents?
Guards
Video Cameras
Other:
What measures are taken to monitor client activities?
What precautions does the Applicant take to prevent non-staff members from accessing
unauthorized areas of the property?
Does the Applicant have incident reporting procedures and committee reviews?
Yes
No
Is the Applicant’s staff made aware of reporting procedures?
Yes
No
Does the Applicant have a plan for medical emergencies?
Yes
No
Is there always someone trained in CPR and first aid on the premises?
Yes
No
Does the Applicant have Automatic External Defibrillator
Yes
No
Are staff members trained to use it?
Yes
No
Does the Applicant have a written and enforced no smoking policy?
Yes
No
Are “no smoking” signs posted in all areas not designated for smoking?
Yes
No
Are smoke detectors installed in all sleeping areas?
N/A
Yes
No
Youth Group Organization Supplemental
Page 2 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
SECTION III – PROFESSIONAL LIABILITY
Hiring Practices
1.
Does the Applicant require their staff (paid and volunteer) to complete an employment application?
Yes
No
If no, please explain:
2.
Does the Applicant share written job descriptions with all staff members?
Yes
No
3.
Name of executive director / manager:
Number of years experience in this field:
Number of years at this facility:
Specialized training or education:
4.
Are any staff members under eighteen (18) years of age?
Yes
No
If yes, list their position(s) and how they are supervised:
5.
What is the staff turnover rate for the last twelve (12) months?
6.
Does the Applicant provide workers compensation for:
All staff members Workshop Employees
Contractors
Consultants
7.
Is the staff required to report to the administrator all incidences that may result in a claim?
Yes
No
If yes, is a written report kept?
Yes
No
Are they reviewed?
Yes
No
8.
Are clients referred to specialists when appropriate?
Yes
No
9.
Are files maintained to protect confidentiality of clients?
Yes
No
10.
Does the Applicant do any consulting work?
Yes
No
If yes, please explain:
11.
Does the Applicant’s current insurance program provide professional liability coverage?
Yes
No
If yes:
Occurrence
Claims Made – Retroactive date:
Limits: $
Effective dates:
Carrier:
12.
Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of:
Full time employees:
Part Time Employees:
Volunteers:
Staffing
# of Employees # of Contracted
Total Annual Volunteer
Hours Worked
FT PT FT PT
Psychologist
Medical Director (Admin Only)
Nurse Practitioner
Physician Assistant
Pharmacist
Paramedic EMT
Psychiatrist
Physician-Hospice
Pediatrician
Physician-No Surgery
Dentist
Optometrists/Ophthalmologist
Licensed Social Worker
Sociologist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance, Vocational)
Social Worker
Occupational Therapist
Speech Therapist
Clergy / Rabbi / Pastor
Youth Group Organization Supplemental
Page 3 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
13.
If the Applicant is requesting primary medical professional coverage for any of above noted Physicians,
Psychiatrists, Dentists or Opticians, the Applicant must submit a completed and signed Medical Professional
application. Coverage for such professional is subject to Underwriting review and approval.
14.
If the above noted employed or volunteer Physicians, Psychiatrists, Dentists or Opticians carry their own medical
malpractice insurance, we may provide vicarious medical professional coverage for the entity as respects to the
professional services rendered on the insured’s behalf. Coverage for the entity will require the following: The
Professional’s name, medical license number, medical specialty and proof that the professional carries adequate
limits of insurance (at least $1million limit of liability). Proof of insurance may be satisfied by submitting a copy of
the professional’s declaration page and/or certificate of insurance.
15.
Consultant / Independent Contractors
Are there written agreements with independent contractors?
Yes
No
Are certificates of malpractice / professional liability insurance obtained and maintained for all
contracted service providers (independent contractors)?
Yes
No
Please indicate the limits of liability: $
SECTION IV – HIRING / SCREENING
1.
Are employees screened for drug, alcohol and sexual abuse?
Yes
No
2.
Check all methods used in hiring all employees or independent contractors:
Drug Testing
Criminal Background Checks – Federal
Criminal Background Checks – State
Personal Interview
Reference Checks
Sexual Abuse Registry
Validate Driver’s License
Validate Education
Validate Work History
Verify Current Certification / Professional License
Validate Personal Auto Insurance and Limits (if operating owned vehicle during company hours)
3.
How are references checked:
Written
Verbal
Both
If verbal only, please explain:
4.
Are all of the above methods done prior to hiring?
Yes
No
If no, please explain:
SECTION V – SEXUAL ABUSE
N/A
1.
Does the Applicant’s current insurance program include Abuse and Molestation Coverage?
Yes
No
If yes, Occurrence or Claims Made – Retro Date:
Limit of Liability: $
Carrier:
Effective Date:
2.
Does the Applicant’s employment process include verification of whether the individual has ever
been convicted of any crime, including sex related or child-abuse related offenses, before an offer of
employment is made?
Yes
No
3.
Does the Applicant have a written crisis plan in place for dealing with employees, victims, parents,
authorities, and the media if the Applicant has incident of abuse?
Yes
No
4.
Are there written complaint procedures and are they displayed prominently?
Yes
No
If yes, explain:
O&P Certified Technician
Teacher
Nutritionist / Dietician
Residential Manager
Home Health Aide
Day Care Worker
O&P Certified Fitter
O&P Certified Assistant
Adoptions
Foster Care
*Other (describe):
*Other (describe):
F/T = Full Time – over 20 hours per week/ P/T = Part Time – up to 20 hours per week.
*Please describe “other” staff positions not listed in the above chart in the provided area.
Youth Group Organization Supplemental
Page 4 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
5.
Is there a written supervision plan that monitors staff in day-to-day relationships with clients, both
on and off premises?
Yes
No
6.
Are formal written procedures in place for hiring?
Yes
No
7.
Do volunteers work directly with clients?
Yes
No
8.
Is there formal staff training on child/sexual abuse, including how to recognize the signs?
Yes
No
9.
What procedures are in place to make sure no relationship occurs between staff and clients?
10.
Are there procedures prohibiting closed door one-on-one meetings / counseling?
Yes
No
11.
Is there more than one person responsible for the welfare of any single patient?
Yes
No
12.
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
Was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
Amount paid for damages to the victim: $
13.
Does the Applicant run criminal background checks on employees?
Yes
No
14.
Does the Applicant run criminal background checks on volunteers?
Yes
No
SECTION VI – SWIMMING POOLS
N/A
1.
Is there a trained lifeguard on duty?
Yes
No
If yes, how many? During what hours?
2.
The pool area includes:
Jacuzzi
Whirlpool
Hot Tub
Spa
Kiddie Pool
Water Slide
Trampoline
3.
Is the pool completely fenced with a self-locking gate?
Yes
No
If yes, what is the height?
4.
Pool location:
Indoor
Outdoor
5.
Is there a diving board?
Yes
No
If yes, what is the height?
6.
Are depths clearly marked?
Yes
No
7.
Is life saving equipment readily accessible?
Yes
No
8.
Is walking surface around the pool non-skid and in good condition?
Yes
No
9.
Is the staff trained in water safety?
Yes
No
10.
Are all areas of the pool, including the bottom, visible at all times?
Yes
No
11.
Are “swim at your own risk” signs posted with pool rules?
Yes
No
Do the posted rules meet state and local regulations?
Yes
No
12.
Is the storage of pool chemicals secured?
Yes
No
13.
How often is the pool cleaned?
14.
Does the Applicant have specific guidelines regarding closing the pool due to water contamination?
Yes
No
15.
Are all swimming pools and spas compliant with the Virginia Graeme Baker Pool and Spa safety
act?
Yes
No
If no, provide time table and action plan:
SECTION VII – PREMISES / LIFE SAFETY
1.
If the building you occupy was built prior to 1971; has it been inspected for lead paint?
Yes
No
If no, what is the plan for abatement?
2.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the PIC approved connectors by a licensed
Electrician?(indicate which one):COPALUM? Yes No AlumiConn?
Yes
No
Date updated:
Please supply retrofit documentation or statement from installing contractor.
3.
Has asbestos material been:
determined not to be present
removed
or
protected to prevent flaking?
4.
Does the Applicant have any plans for renovations or new construction?
Yes
No
5.
Does the Applicant’s facility exit directly to the outside?
Yes
No
To ground level?
Yes
No
6.
Are there any non-ambulatory clients?
Yes
No
If yes, how many?
Any located above the first floor?
Yes
No
7.
Please indicate which of the following fire suppression devised are currently in use:
Automatic Sprinkler System
Central Station Fire Alarm System
Smoke Detectors
Manual Pull Fire Alarms
Fire Extinguishers
Other:
8.
Are all areas of buildings with wet pipe sprinkler systems (hidden or unhidden) maintained at a
minimum temperature of 40° F, and / or provided with proper insulation or heat tracing to prevent
pipe freeze-ups?
Yes
No
Youth Group Organization Supplemental
Page 5 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
9.
How many exits are there?
Are all exits clearly marked & illuminated?
Yes
No
10.
Are all exit doors equipped with panic hardware?
Yes
No
11.
Is there a fire escape?
Yes
No
If yes, please describe:
12.
Does the Applicant have a written emergency evacuation plan?
Yes
No
If yes, are the emergency evacuations procedures and floor plan posted?
Yes
No
Has Applicant established a central meeting point outside the building?
Yes
No
Does the emergency plan include notification to the fire department?
Yes
No
How often are drills held?
13.
Does the Applicant have emergency lighting or backup generators in the event of a power failure?
Yes
No
14.
Does the Applicant have a formal maintenance housekeeping program in place?
Yes
No
15.
Does the Applicant own or rent any parking facilities?
Yes
No
If yes, are they well lit?
Yes
No
16.
Is the hot water heater set to a temperature of 120 degrees?
Yes
No
Does the Applicant have an equipment maintenance program in place?
Yes
No
17.
Has the Applicant’s facility been inspected by an insurance company or independent inspection
firm?
Yes
No
If yes, by whom?
List any deficiencies and corrective actions in the past three (3) years:
18.
Does the Applicant comply with board of health regulations and with building codes?
Yes
No
19.
Are medical facilities, such as a first aid or nurse’s station located on the premise?
Yes
No
20.
Please indicate the dates of the latest updates regarding the following common hazards:
Electrical/Wiring:
Plumbing:
Heating:
Type of Heating:
Type of Roof:
Age of Roof:
SECTION VIII – KITCHEN EXPOSURE
N/A
1.
Is cooking permitted on the premises?
Yes
No
2.
Is the actual cooking of food prepared and cooked by the staff?
Yes
No
3.
Are there fire extinguishers in the cooking area available?
Yes
No
4.
Is the cooking equipment:
Residential
Commercial
5.
Cooking equipment is equipped with:
Nothing
Hoods
Ducts
Exhaust Fans
Automatic Fire Suppression System
Automatic Fuel shut off control
6.
How often is the cooking equipment cleaned?
7.
Is the cleaning equipment:
Cleaned by Applicant
Cleaning Contractor
If Applicant uses deep fat fryers, grills, or other cooking equipment other than a range, microwave
or countertop electric heating device, please complete the following.
a.
Do all deep fat fryers have high limit switches?
Yes
No
b.
Does the extinguishing system have an accessible manual release control?
Yes
No
c.
List the brand name and age of the extinguishing system:
d.
Is the system U.L. listed?
Yes
No
e.
Is there an inspection / maintenance agreement?
Yes
No
If yes, what is the frequency?
f.
How often is the hood and ductwork professional cleaned?
g.
What is the frequency and method of cleaning hoods and grease filters?
h.
Are grills equipped with grease traps?
Yes
No
i.
Are all flammables and combustibles (like paper goods, etc.) stored separately from ignition
sources (like cooking areas, propane, etc.)?
Yes
No
SECTION IX - SECURITY
1.
Does the Applicant have a written crisis management / emergency plan in effect?
Yes
No
Does the plan apply to both on-premises and off-premises situations?
Yes
No
Youth Group Organization Supplemental
Page 6 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
3.
Has the Applicant ever received any citations or warnings issued by any governmental entity?
Yes
No
Please explain:
SECTION X - AUTOMOBILE
N/A
1.
Are all vehicles listed on the ACORD application titled to the Applicant?
Yes
No
If no, please explain:
2.
Where does the Applicant keep their owned vehicles?
Garage
Driveway
Parking Lot
Other:
3.
Are keys locked and secured away from non-drivers when not in use?
Yes
No
4.
Are vehicles with eight(8) or more seating capacity equipped with an audible backup warning
device?
Yes
No
5.
Does the Applicant provide pickup or delivery of donated merchandise?
Yes
No
6.
Does the Applicant provide transportation for:
Staff
Clients / Residents
Visitors / Public
Meals
If yes for clients / residents, is more than one staff member required in the vehicle?
Yes
No
If yes for meals, what precautions do you take to prevent food spoilage?
7.
Does the Applicant transport clients / consumers for other private or government agencies?
Yes
No
If yes, please explain:
If yes, for a fee?
Yes
No
8.
Does the Applicant provide transportation for field trips?
Yes
No
If the Applicant does not provide transportation, how is it provided?
If vehicles are hired for field trips, are they hired with a driver?
Yes
No
9.
Do employees/volunteers transport clients in their own vehicles?
Yes
No
If yes, how often?
10.
Are vehicles checked after passengers disembark to make sure no one is left behind?
Yes
No
11.
Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair & passenger?
Yes
No
12.
Does the Applicant require seat belts to be worn by all occupants?
Yes
No
13.
Does the Applicant have a vehicle maintenance program in place?
Yes
No
14.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
15.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
SECTION XI - DRIVERS
N/A
1.
Does the Applicant obtain a written authorization to release driver information from all of the
Applicants staff upon hiring?
Yes
No
Does the Applicant obtain MVRs on all drivers?
Yes
No
If yes, how often?
2.
What are the Applicant’s procedures for dealing with driver accidents or violations?
3.
Are all drivers at least twenty-one (21) years of age?
Yes
No
4.
How many drivers (employees and volunteers) aged twenty-one (21) to twenty-five (25) transport
clients in agency vehicles?
5.
Do any drivers have a Commercial Driver’s License (CDL)?
Yes
No
6.
Explain the Applicant’s driver safety program:
2. Describe the type of security measures currently in place to prevent the general public from gaining
access to the building and the clients.
Youth Group Organization Supplemental
Page 7 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
7.
Is training provided for new employees / volunteers prior to their transporting clients?
Yes
No
If yes, please explain:
8.
Does anyone besides employees or volunteers drive the Applicant’s vehicles?
Yes
No
If yes, please explain:
9.
Does the Applicant allow personal use of the Applicant’s agency vehicles?
Yes
No
If yes, by whom and for what reasons?
SECTION XII – HIRED AND NON-OWNED VEHICLES
N/A
1.
Does the Applicant hire vehicles?
Yes
No
If yes, what type of vehicles does the Applicant hire?
Does the Applicant obtain Certificates of Insurance from vehicle owners?
Yes
No
What minimum limits does the Applicant require? $
2.
Does the Applicant hire from a transportation company?
Yes
No
If yes, with drivers?
Yes
No
3.
Total number of hired vehicles:
Annual cost of hire: $
4.
How many of the following drive personal vehicles for business use regularly?
F/T:
P/T:
Vol:
How many of the following drive personal vehicles for business use occasionally?
F/T:
P/T:
Vol:
Does the Applicant obtain proof of insurance for employees / volunteers who use their own autos?
Yes
No
Does the Applicant update these records at least yearly?
Yes
No
What minimum limits does Applicant require? $
SECTION XIII – DAY CARE
N/A
LICENSING:
1.
Is the center licensed?
Yes
No
2.
If licensing is NOT required, why is the center exempt?
3.
Has a license to operate ever been denied, suspended or revoked?
Yes
No
Attach a separate full explanation.
4.
Has the Applicant ever been brought up for a compliance hearing?
Yes
No
If yes, explain thoroughly on a separate document.
STAFF AND CHILDREN: (The ratios of staff-to-children must be at least the state required ratio)
1.
Based on the maximum number of children enrolled on your busiest day OR busiest session, enter the numbers
of staff and children in each of the following age groups. (Do not duplicate pre and after school children if they stay
all day)
CHILD AGE GROUP
# OF CARE PROVIDERS
# OF CHILDREN
# OF CHILDREN
Less than 18 Months
18 - 30 Months
31 Months - 4Years
Above 4 Years
Preschool (only)
Enter in cell to right
After school (only)
Enter in cell to right
2.
Is any staff less than 18 years old?
Yes
No
Indicate specific duties for each on a separate document.
3.
Does the Applicant use any volunteers?
Yes
No
Indicate specific duties for each on a separate document.
Youth Group Organization Supplemental
Page 8 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
HEALTH:
1.
Does the Applicant provide sick child, drop-in, latch-key, boarding or camp services?
Yes
No
If yes, please explain:
2.
How many children require special care and treatment?
Please explain:
3.
Indicate if a file containing the following information is maintained on each child:
a.
Immunization records of the children being immunized successfully, and updated annually?
Yes
No
b.
Records for each child indicating unusual conditions the child has?
Yes
No
c.
Signed releases for emergency medical treatment/dispensing of medication obtained from
parents?
Yes
No
d.
Written instructions from child’s physician for dispensing of child’s medication?
Yes
No
4.
Is food properly covered, stored and served in accordance with applicable government
requirements?
Yes
No
5.
Does the Applicant have an accident/health policy?
Yes
No
a.
Is coverage mandatory for all children?
Yes
No
b.
Provide Carrier:
c.
Policy Term:
Limits: $
SECTION XIV - CAMPS
N/A
1.
Is written permission and waiver of liability obtained from every child’s parent or guardian?
Yes
No
2.
Does the camp provide overnight services?
Yes
No
If yes, what is the average length of stay?
3.
Total number of days in operation annually:
4.
Number of children at each camp:
5.
Number of staff members at each camp:
6.
What are the qualifications of staff working with children?
7.
Are sleeping quarters co-ed?
Yes
No
8.
Are restrooms / showers co-ed?
Yes
No
9.
If well water, how often is it tested?
10.
Indicate and describe if any of the following exposures exists in the camp operations:
Obstacle course
Rock climbing
Motor boats
Horses
Lakes
Guns
Diving boards
Water skiing
Jet skis
Archery
Pools
SECTION XV – ATHLETIC ACTIVITIES
1.
Does the Applicant obtain a signed release which includes a hold harmless agreement from the
parents/guardians of all participants and obtained annually?
Yes
No
2.
Are there procedures in place to verify that parents / guardians carry their own health insurance?
Yes
No
3.
Are medical exams required for all participants in extra-curricular sports?
Yes
No
4.
Are all instructors Applicant’s employees?
Yes
No
5.
Is someone who is trained in first aid always present during practices and games?
Yes
No
6.
Is Student Accident Insurance carried?
Yes
No
If yes, what is the limit carried?
7.
Does the Applicant have a written concussion management protocol that is compliant with current
state legislation?
Yes
No
a.
Does the Applicant distribute the written protocol to coaches, parents, and players, and require
the parent / guardian’s acknowledgement that they have received and reviewed?
Yes
No
b.
Does the protocol include training in recognizing the signs / symptoms of a concussion or
other closed head injury?
Yes
No
c.
Does the Applicant utilize base line testing?
Yes
No
Is the training required for all coaches and faculty involved in physical education or sports
instruction?
Yes
No
e.
Does the protocol when a concussion is suspected require:
removing the athlete or student from play?
Yes
No
evaluation by an appropriated healthcare professional?
Yes
No
Youth Group Organization Supplemental
Page 9 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
informing the athlete or students’ parents / guardians about the possibility of a
concussion and giving them information about concussions?
Yes
No
keeping the athlete or student out of play until an appropriate healthcare professional
certifies that the athlete or student is symptom free and gives the OK for them to return
to play?
Yes
No
8.
Does the Applicant have any saddle animals or equestrian teams?
Yes
No
9.
Does the Applicant have any swimming pools on the premises?
Yes
No
If yes, are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety
Act?
Yes
No
If no, provide time table and action plan:
10.
Number of athletic trainers:
11.
Is the Applicant compliant with the Zackery Lystedt law? (only applicable in WA)
Yes
No
12.
Bleachers:
# of Outside:
Seating capacity:
How often inspected:
# of Inside:
Seating capacity:
How often inspected:
13.
Are any of the following offered? (check all that apply)
Archery
Community Service
Martial Arts
Sky Diving
Baseball
Diving
Motorbikes/Minibikes
Snow Skiing
Basketball
Environmental Education
Motorcycles/ATVs
Soccer
Bicycle Trips
Equestrian
Mountain Biking or BMX
Softball
Boxing
Field Hockey
Paintball
Swimming
Bungee Jumping
Football (tackle)
Polo
Trampoline
Ceramics / Pottery
Football (touch or flag)
Rocketry, Model Rockets
Wall Climbing
Cheerleading
Go Karts
Roller Skating / In-Line Skating
Water Skiing
Climbing (Mountain, Rock
or Wall)
Gymnastics
Rugby
Woodworking
Crew/ Rowing
Hiking / Backpacking
Scuba Diving
Wrestling
Cross Country Track
Ice Hockey
Skateboarding
Other Unique Activities (Describe):
Depending on the activities indicated additional Underwriting information may be necessary. Some
activities may be excluded from coverage after our evaluation.
SECTION XVI – TRIPS / FIELD TRIPS / TRAVEL
N/A
1.
How many trips are sponsored each year?
2.
Are all trips within the United States, U.S. Territories, or Canada?
Yes
No
If no, where are trips taken?
3.
Do any trips last more than one day?
Yes
No
If yes, describe duration, destination(s) and purpose:
4.
What is the ratio of adult staff to participants by age group?
5.
Are signed permission and waiver agreements obtained from the custodial parent(s) for all trips a
participant takes?
Yes
No
If no, explain Applicant’s procedure for permissions and waivers:
6.
Do all parents receive detailed information about the trip (place, transportation, supervision, times),
objectives, necessary provisions and instructions prior to the trip?
Yes
No
7.
Do all participants wear identification tags or identifiable clothing on all trips?
Yes
No
8.
Does the Applicant hire an outside firm to arrange the trips?
Yes
No
9.
Are participants allowed to drive their own cars on trips?
Yes
No
Youth Group Organization Supplemental
Page 10 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
If yes, are they allowed to transport other participants?
Yes
No
10.
Is proof of insurance required for anyone who drives their own vehicle on a sponsored trip?
Yes
No
11.
Is there a formal policy regarding emergencies and trained personnel on all trips?
Yes
No
SECTION XVII – SPECIAL NEEDS PARTICIPANTS
N/A
1.
What percent of the Applicant’s participants have special needs? %
2.
Do any of the Applicant’s supervisory personnel have experience in an area relevant to the special
needs participants you serve?
Yes
No
If yes, describe type, training, and length of experience:
3.
Are staff ratios adjusted for special needs participants?
Yes
No
If yes, what is the ratio? staff to special needs participants
4.
Is the supervisory staff informed about the limitations/abilities of the special needs participants
regarding activities, diet, medical requirements, etc.?
Yes
No
5.
Does the Applicant’s crisis management plan include contingency plans for these participants?
Yes
No
6.
Does the Applicant provide additional services, such as counseling hot lines, seminars, or other
activities specific to special needs populations or their families?
Yes
No
If yes, describe:
SECTION XVIII– FACILITY RENTAL
N/A
1.
Does the Applicant rent a facility to any outside groups?
Yes
No
2.
Is a written lease required for every rental?
Yes
No
3.
Does the Applicant obtain a certificate of insurance with liability limits of at least $1,000,000?
Yes
No
If yes, is the Applicant named as an additional insured on the lessee’s liability insurance policy?
Yes
No
4.
What are the Applicant’s gross receipts from all rental operations? $
5.
What activities are offered to rental groups?
Does the Applicant provide supervision of any of these activities?
Yes
No
If yes, which activities?
Number of individuals/day: Number of rental days/week: Number of weeks/year:
6.
Are all safety requirements spelled out in writing in the lease agreement?
Yes
No
SECTION XIX – CLAIMS MADE
N/A
Notice: This section is being completed as an application for a Claims-Made policy. Only claims which are first
made against the Applicant and reported to us during the policy period or Extended Reporting Period will be
covered, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire policy
carefully to determine the Applicant’s rights, duties and what is and is not covered.
N/A (Please proceed to signature section)
Policy Effective Date:
Line of Business:
1.
Within the past 5 (five) years has the Applicant given written notice under the provisions of any
current or prior policy providing similar insurance of any claim or of any specific facts or
circumstances which might give rise to a claim being made against the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might
give rise to a claim under the coverage(s) for which the Applicant is applying?
Yes
No
If yes, please provide details:
Youth Group Organization Supplemental
Page 11 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
SECTION XX - DIRECTORS & OFFICERS / EMPLOYMENT PRACTICE LIABILITY
N/A
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets:
$
$
Net Assets / Fund Balance:
$
$
Annual Revenue:
$
$
Net Revenue:
$
$
3.
Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the Applicant
Owns/Controls
Date Created /
Acquired
For Profit / Non-
Profit
I.E.: ABC Foundation / Charitable Foundation
100%
01/01/2000
Non-Profit
%
%
%
Additional entities listed by attachment
4.
Has the Applicant or any person proposed for coverage herein been the subject of, or involved in,
any of the following in the past five (5) years? If yes, please attach details.
Yes
No
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in any merger,
acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION:
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
2.
Has a reduction in employees or change in of status occurred in the past 12 months or is anticipated
in the next 12 months?
Voluntary:
Involuntary:
Layoffs:
3.
Does the Applicant have an employment handbook that includes an “At Will” statement?
Yes
No
4.
Does the Applicant use an employment application for every potential employee?
Yes
No
5.
Does the Applicant use outside employment counsel for employment advice?
Yes
No
6.
Does the Applicant have a full time, dedicated human resource staff?
Yes
No
Youth Group Organization Supplemental
Page 12 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
7.
Total number of current employees with annual compensation greater than $100,000:
CURRENT COVERAGE:
COVERAGES
Insurance Company
Limit of
Liability
Deductible
Policy Effective
Dates
Premium
D & O
$
$
$
EPLI
$
$
$
Fiduciary
$
$
$
Workplace Violence
$
$
$
Internet Liability
$
$
$
WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed coverage?
(Not Applicable in Missouri)
Yes
No
If yes, please provide details:
2.
Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance or claims, or of specific facts or circumstances which might give rise to a claim being made
against any person or entity applying for this insurance?
If yes, complete a Claim Supplemental for each incident.
Yes
No
3.
No person applying for this coverage is aware of any facts or circumstances which he or she has
reason to suppose might give rise to a future claim that would fall within the scope of any of the
proposed coverages for which the Applicant has applied, except: None or as noted below.
With regard to questions 2. and 3., it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission, dispute or
circumstance is excluded from coverage that may be provided under this proposed insurance and, further,
failure to disclose such claim, act, error, omission, dispute or circumstance may result in
the proposed
insurance being void, and/or subject to rescission.
Youth Group Organization Supplemental
Page 13 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
SECTION XXI - WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization review?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (i.e. temperature
monitoring, heat trace, full insulation on piping or roof):
6.
General Comments:
Youth Group Organization Supplemental
Page 14 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Print Application
Clear Application
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
______________________________
_______________________________
SIGNATURE DATE
SECTION TO BE COMPLET
ED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Youth Group Organization Supplemental
Page 15 of 17
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against t
he Applicant alleging
invasion or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
Page 1 of 2
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
__________
___________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
Page 2 of 2
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Youth Organizations36-9283

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document